Lecture on Clinical Methods; Anterior Segment Proptosis & Ptosis examination For 4th Year MBBS Undergraduate Students By Prof. Dr. Hussain Ahmad Khaqan

1. Clinical Methods; Anterior Segment,
Proptosis & Ptosis
Prof. Dr. Hussain Ahmad Khaqan
 MD
 FRCS(Glasgow)
 FCPS(Ophth.)
 FCPS(Vitreo Retina)
 MHPE (KMU)
 CICO(UK)
 CMT(UOL)
 Fellowship in Medical Retina (LMU, Munich)
 Fellowship in Vitreo Retinal Surgery (LMU, Munich)
 Consultant Ophthalmologist & Retinal Surgeon
Professor of Ophthalmology
Lahore General Hospital, Lahore
Ameer Ud Din Medical College, Lahore
Post Graduate Medical Institute, Lahore
Shaukat Khanum Memorial Cancer Hospital & Research Centre ,Lahore

2. CLINICAL METHODS; ANTERIOR SEGMENT

3. 1. Introduce yourself
2. Observe the patient as a whole with the room lights
on. This may provide diagnostic clue to your slit-
lamp findings for example: acne rosacea
(blepharitis, pannus and corneal thinning; atopic
eczema (associated with keratoconus and
premature cataract); heterochromia (siderosis oculi
or heterochromiccyclitis); hypopigmentation of the
skin and hair (oculocutaneous albinism)
3. Set up your slit lamp and ensure that:
a. The patient is comfortable with their forehead against
the head rest
b. Binocular vision is obtained by adjusting the inter-
pupillary distance, and the ocular eye-pieces

4. 4. Begin (with low magnification, diffuse illumination
and neutral density filter) by examining the eyelids
and eyelashes for :skin tumors, blepharitis, loss of
eyelashes or white lashes
5. Examine the tarsal conjunctiva by everting the lids.
6. Observe for : pigmented lesions (such as naevi,
melanoma or adrenochrome deposits ) subtarsal
fibrosis and symblepharon (seen in ocular cicatricial
pemphigoid and stevens-johnsons syndrome)
7. Examine the bulbar conjunctiva for: pigmentation,
degenerative changes or trabeculectomy

5. 8. Examine the cornea (low and high magnification) in
layers (diffuse illumination
>parallelipipied>retroilllumination> specular
microscopy if endothelial lesions suspected >sclerotic
scatter ) noting:
a. Opacities (e.g. iron deposits in the epithelium, calcium in
Bowman’s layer, stromal dystrophies, keratic precipitates,
guttata or pigment cells on the endothelium)
b. Structural changes (e.g. peripheral corneal thinning,
central corneal thinning, and Vogt’s striae in
keratoconus, descemet’s membrane breaks and
increased corneal diameter in buphthalmos)
9. Examine the anterior chamber. Look for flare and cells
or foreign material. Assess the anterior chamber depth.

6. 10. Examine the iris for : atrophy (iridoschisis,
Iridocorneal endothelial (ICE) syndrome, and
anterior cleavage syndrome); pigmentation (from
pigment dispersion syndrome, melanoma or
pseudoexfoliation syndrome), abnormal vessels
(from rubeosis irides, Fuch’s heterochromic uveitis
and rarely iris microextraction)
11. Examine the lens for : abnormalities of the lens
surface( pseudoexfoliation, glaucomflecken in
previous acute glaucoma or anterior lenticonus)
cataract and posterior lens surface (posterior
lenticonus or hyaloid artery remnant)
12. Examine the anterior vitreous for : cells, operculum
or posterior vitreous detachment

7. 13. Examine the posterior segment with the lens (60,
78 or 90 D)in a methodical way. Ask the patient to
fixate on a target such as your right ear when you
examine the right eye and vice versa. Remember
that the image you see is inverted and the
magnification decreases when the diopter power of
the lens increases.
a. Vitreous
b. Optic nerve head
c. Retinal vessels
d. Macula
e. Periphery

8. METHODS OF SLIT LAMP
1. Diffuse illumination
2. Parallelipipied illumination/direct illumination
3. Sclerotic illumination
4. Specular illumination
5. Retroillumination
6. Measurement of anterior chamber depth
a) Van Herrick (peripheral anterior chamber (AC) method)
b) Redman-smith (central anterior chamber (AC) depth)

9. DIFFUSE ILLUMINATION
• The light is shone on the cornea with diffuse
illumination angled at 45 degrees from the
microscope position. The illuminated area is viewed
through the microscope oculars. This should be the
initial corneal examination.

10. PARALLELIPIPIED ILLUMINATION/
DIRECT ILLUMINATION
• A beam of light with a width of about 2 mm is
directed at the cornea at 45 degrees from the
microscope position. This allows one to view a 3-
dimensional block of cornea. The posterior surface of
the cornea can be examined for keratic precipitates,
guttata or pigment.

11. SCLEROTIC ILLUMINATION
• This is useful in detecting subtle corneal opacities. A
beam of light is de-focused onto the limbus. It gives
rise to total internal reflection within the corneal
stroma. If there is no opacity the cornea will appear
uniformly dark. Otherwise, any corneal opacity will
scatter the light and appear as a bright area within a
dark cornea.

12. SPECULAR ILLUMINATION
• A thin beam of light and the microscope are placed
at equal angles from the normal to the cornea. This
technique is particularly useful for observing
endothelium-aqueous interface abnormalities e.g.
corneal guttata. High magnification (25 times
achievable using the x16 oculars) is needed and
viewing is performed monocularly.

13. RETROILLUMINATION
• This technique is used to examine the cornea by
reflecting light off a solid body (the iris, lens and
retina). This gives the effect of having the light source
arising from behind the object observed. It is also
useful for observing iris transillumination and lens
opacities.

14. MEASUREMENT OF ANTERIOR CHAMBER DEPTH
CONTINUE..
• Van Herrick (Peripheral anterior chamber Method)
• This is based on the fact that the width of the angle of the
anterior chamber correlates to the distance between the
posterior corneal surface and the anterior iris as viewed near
the corneal limbus.
• Steps:
1. At the slit-lamp, direct a narrow slit beam at the temporal
or nasal corneal surface.
2. View from the straight ahead position and compare the
depth of the anterior chamber to the thickness of the
cornea.

15. Results:
1. Grade 4, anterior chamber depth is equal to or greater than
the corneal thickness; corresponding to a wide open angle
2. Grade 3, anterior chamber depth is equal to one half the
corneal thickness; the most common angle width
3. Grade 2, anterior chamber depth is equal to one fourth the
corneal thickness
4. Grade 1, anterior chamber depth is less than one fourth
the corneal thickness; corresponding to a very narrow
angle.

16. Redman-smith (Central anterior chamber Depth)
• Steps:
1.Set slit beam mounting at 60 degrees to microscope
2.Use horizontal slit beam
3.Focus at a point in the middle of the anterior chamber
4.Adjust slit beam length to join corneal and iris reflections
5.Measure the slit length on the graticule in mm
Measurement x1.1+0.5 = anterior chamber depth
MEASUREMENT OF ANTERIOR CHAMBER DEPTH

17. CLINICAL METHODS; PROPTOSIS

18. PROPTOSIS
1. Introduce yourself
2. Observe the patient from the front for any
external signs such as lid retraction, conjunctival
redness and arterialization of the scleral vessels
(carotico-cavernous fistula)

19. 3. Now assess if the proptosis is axial or non-
axial by placing a transparent ruler
horizontally across the nose. Look for any
horizontal or vertical deviation. Examining
the corneal reflexes is an alternative to using
the ruler.
4. Dim the lights and check for relative afferent
pupillary defect (RAPD)

20. 5. Confirm the presence of proptosis by looking
from the side, and them from behind and
above, the patient. From behind, palpate the
neck and ask the patient to swallow.

21. 6. Perform ocular motility examination as
thyroid eye disease is the most common
clinical case. Look for upgaze restriction and
lid lag. In carotico-cavernous fistula, the eye
may be ‘frozen’ due to ocular nerve
involvement. Assess for lagophthalmos, Bells
reflex and exposure keratopathy.

22. 7. Ask to palpate along the margin of the orbit
and feel for masses and retropulsion. Palpate
the auricular and submental regions for
lymphadenopathy.
8. Ask to listen for bruit over the closed eye
with the bell of the stethoscope.

23. 9. To complete the examination, ask to examine or
mention that you would like to perform:
a. Measurement of proptosis using an exophthalmometer
(hertel’s exophthalmometer). Before you use the
instrument, anesthetize the patient’s eyes and make sure
the exophthalmometer is wide open otherwise it can
appear menacing to the patient. Place the footpieces
against the lateral orbital rim. Note the base
measurement (the distance between the two orbital
rims) and the position of the cornea is read off the scale.
b. Visual function
c. Peri-orbital sensation (for trigeminal nerve involvement)
d. Slit-lamp examination for exposure keratopathy,
intraocular pressure (IOP) in straight/upgaze, optic nerve
cupping, choroidal folds etc.

24. 10.Findings:
a. In thyroid eye disease, look for goiter or
thyroidectomy scar, tachycardia, tremor of the
hands, thyroid acropachy and pretibial
myxedema
b. If the cause were uncertain, give a differential
diagnosis according to whether the proptosis is
axial or non-axial. Axial proptosis suggests a
lesion that arises from within the muscle cone
such as cavernous hemangioma whereas non-
axial proptosis suggests an extraconal lesion, e.g.
downward proptosis may be due to a frontal
mucocele and a down-and-in proptosis may be
due to a lacrimal gland tumor.

25. CLINICAL METHODS;PTOSIS

26. PTOSIS
1. Introduce yourself
2. Observe the patient for any obvious ptosis,
strabismus (third nerve palsy or myasthenia gravis)
or anisocoria (horner’s syndrome or third nerve
palsy)

27. 3. Measure the middle interpalpebral distance (in
mm)with a transparent ruler. Then measure the
skin crease by getting the patient to look down;
this is the distance between the lid crease and the
lid margin. Do not forget to measure the marginal
reflex distance. This is done by sitting opposite the
patient at the same eye level and shining a light
into the patient’s eye. Two marginal reflex
distance are measured:
a. The distance from the reflex to the middle of the lower lid
margin
b. The distance from the reflex to the middle of the upper lid
margin

28. 4. Check the levator function. This is determined by
measuring the excursion of the lid margin as the
patient looks from extreme downgaze to full
upgaze. To prevent the frontalis coming into play,
put your thumb on the eyebrow during the
excursion.

29. 5. Test for bell’s phenomenon. This is performed
by holding the upper lid open with your
fingers and asks the patient to forcibly shut
his eyes. The phenomenon is present if his
eyes are seen rolling up. Mention you
would also like to test the corneal
sensation.

30. 6. After examining the ptosis from surgical
view point, the next step is to find the
cause. The following steps are performed
as necessary:
a. Marcus-gunn winking ptosis is a common clinical
case especially if the patient is young. Get the
patient to open his lower jaw and ask him to
move it from side to side to elicit the wink.
b. Take a close look for pupil asymmetry and
heterochromia (congenital Horner’s syndrome)

31. c. Perform a cover test for vertical tropia (hypotropia
can cause pseudoptosis)
d. Perform ocular motility test for partial third nerve
palsy or myasthenia gravis.
e. Test for fatiguability by getting the patient to look up
for about 15seconds and look for increased ptosis.
f. Cogan’s lid twitch sign may be present in myasthenia
gravis i.e. attempted rapid saccades from downgaze
to the primary position may provoke an overshoot of
the upper eyelid above the superior limbus with a
gradual fall of the lid to its original position.